668
As far as the case report of Dr Lewis and others is concerned, it would be useful to know if the patient had acute or fulminant changes of exophthalmos, for without these changes their patient would be similar to one of our own who did not respond. The lack of response in such patients is probably due to permanent fibrotic changes in extraocular muscles. In this regard it would be extremely useful to have a simply measured biochemical marker which would predict potential responders. For the moment, however, it appears that one would have to depend on the clinical indications such as those described above; this is not necessarily a compromise since it is mostly in association with these features that the threat to visual acuity occurs. Plasmapheresis is not a treatment for cosmetic discomfort but a possible alternative to orbital decompression. We agree that this procedure needs further assessment. P DANDONA N MARSHALL S BIDEY A W NATHAN C W H HAVARD Metabolic Unit, Royal Free Hospital, London NW3 2QG
Autonomic neuropathy in the Guillain-Barre syndrome SIR,-Further to your correspondence regarding heart rate variation in diabetes mellitus and in tetraplegic patients (19 May, p 1353) we would like to report a case of GuillainBarre syndrome in which serial tests showed the presence and then resolution of an autonomic neuropathy.
BRITISH MEDICAL JOURNAL
monitored closely in this syndrome, both to rheumatoid disorders. However, they did not assess progress and to provide objective need to refer to a newspaper as a source of reference, since the matter has received wide parameters with which to assess therapy. publicity in the Dutch medical press. After the first warning that analysis of such M E EDMONDS R D STURROCK pills had shown the presence of indomethacin and dexamethasone, and that cases of Department of Therapeutics, Westminster Medical School, Cushing's and withdrawal syndrome London SW1O 9TH symptoms after stopping treatment had been Ewing, D J, et al, British Medical Journal, 1978, 1, 145. reported,' a case similar to Dr Forster's was 2 Sundkvist, G, et al, British Medical Journal, 1979, 1, published,2 involving a patient who had been 924. 3Birchfield, R I, and Shaw, C-M, Archives of Neuirology, using 12 pills daily containing an average of 1964, 10, 149. 75 mg indomethacin, 112 ug dexamethasone, 4 Appenzeller, 0, and Marshall, J, Archives of Neu4roand small quantities of diazepam and hydrology, 1963, 9, 368. chlorothiazide. These pills had been manufactured by the Nan Lien Pharmaceutical Co Ltd in Hong Kong. Similar pills from the Singapore subsidiary of the same firm were Diving and hypothermia shown to be composed of prednisone 0 4 mg, SIR,-Another two divers in the North Sea hydrochlorothiazide 4 mg, chlordiazepoxide have died from hypothermia and I should like 0 5 mg, chlorpheniramine maleate 1 3 mg, to add to the recent contributions on this and thiamine disulphide 5 mg; whereas the subject (5 May, p 1182; 9 June, p 1566; pills marketed by the Shou Sing Pharmaceutical Co Ltd in Taiwan contain varying 25 August, p 494). Divers under water lose heat from the body (0 6-6 mg) amounts of phenylbutazone, about surface and through respiration, the latter in 8 mg of aminopyrine, and some thiamine. two parts-(a) the humidification of dry Moreover, the Yi Chung Tai Medical Manuinspired gas and (b) absolute warming of the factory Co Ltd in Taiwan markets Chicold inspired gas. With a helium-oxygen Shi-Ton pills containing 8 1 mg paracetamol, respiratory mixture the absolute warming part 0-26 mg ethaverine hydrochloride, 2 mg of the respiratory heat loss becomes much chlorzoxazone, 0-55 mg diazepam, 1 9 mg more important than in air. Under normal caffein, and some thiamine.1 In none of these circumstances heat supplied from the support cases was the presence of these drugs ship to the diving bell via the umbilical cord mentioned on the package or the directions counteracts the heat loss; but in any accident folder. Obviously patients suffering from normal sources of power and heat will almost rheumatoid arthritis run great risks in the certainly be lost, as happened in the Thistle unauthorised use of such adulterated pills. Though marketing-mostly by small field, or at best reduced. When this happens the men are in trouble and emergency equip- Chinese dealers-of these pills in the ment should therefore be effective without Netherlands is alleged, and since October 1978 has been officially condemned, a total requiring any outside source of power. Respiratory heat loss could be reduced by embargo on this dangerous practice seems means of a heat exchanger which also acts as a almost impossible to enforce. Patients should condenser humidifier. A soda-lime-filled cani- therefore be clearly warned against the use of ster, as used in anaesthetics but with the any Chinese so-called herbal pills. This is not addition of insulation, could fulfil this need. the only example of its type; similar instances The soda-lime granules would initially act as a (Amborum Spezial F, Tsai-Tsao-Wan, passive-condenser humidifier and heat ex- "nose pills," and Swasahar) have been changer, but as the expired carbon dioxide reported from Germany, Australia, and the reacted with the soda lime to produce heat and United States.4 L OFFERHAUS moisture the system would gradually change M N G DUKES to one providing a positive heating effect. Of course, as the soda-lime became exhausted the Division of Pharmacotherapy, Drug Inspectorate, canister would revert to a passive heat and Cenltral Ministry of Public Health and Environmental Hygiene, moisture conserver. A single canister should nevertheless provide about six hours of Leidschendam, The Netherlanids H M SMITS positive heating and CO2 absorption. The provision of the insulated canisters State Institute for Drug Research, would encroach on the space in the diving bell Leiden, The Netherlands but a space of 30 x 15 cm diameter per man Offerhaus, L, Nederlandsch Tijdschrift voor Geneesmight not seem excessive for an emergency. kunde, 1978, 122, 1633. Uitdehaag, C M J, Nederlandsch 7'zjdschrift voor the fitting be (a) The other problems would Geneeskunde, 1979, 123, 1009. canister into the diver's breathing system; Central Drug Inspectorate, Nederlandsch lijidschrift voor Geneeskunde, 1979, 123, 1347. (b) a slight increase in resistance to breathing; Dukes, N M G, (editor), Side Effects of Druigs Annual and (c) a gradual increase in dead space as 3, Amsterdam, Excerpta Medica, 1979. the soda lime became exhausted.
A 30-year-old man presented to the casualty department with a seven-day history of numbness paraesthesiae of both legs and hands and a left facial weakness which had been present for two days. On examination, his temperature was 37-2°C; pulse rate 124 beats/min, regular; and blood pressure 120/80 mm Hg lying down, 110/80 mm Hg standing. There was a left lower motor neurone facial palsy, a proximal weakness of all four limbs, and sensory loss of a glove and stocking distribution with absent deep tendon reflexes. Investigations: haemoglobin concentration 15 9 g/dl, white blood cells (WBC) 10 5- l09/l; cerebrospinal fluid WBC< 1 x 106/1; protein 2-3 g/l. Electromyography showed slowing of sensory and motor conduction. A diagnosis of Guillain-Barr1 syndrome was made and corticotrophin therapy started. In view of the marked resting tachycardia serial tests for autonomic neuropathy were performed. The heart rate response to standing was conducted as described by Ewing et all and the "30:15 ratio" derived. The variation in heart rate during respiration was recorded by continuous electrocardiographic monitoring during deep breathing (six deep breathing manoeuvres in one minute) and the E:I ratio of the mean of the longest R-R interval during maximal expiration to the mean of the shortest during maximal inspiration was calculated as described by Sundkvist et al.2 For E LL LLOYD the first three days of his admission there was a persistent tachycardia and both the "30:15" and Department of Anaesthetics, Infirmary, the EB: ratios were compatible with vagal neuro- Royal Edinburgh EH3 9YW pathy and autonomic dysfunction. His neurological signs were unchanged. On the fourth day, however, these ratios returned to within the normal range. This was followed by a gradual resolution "Herbal" medicines and rheumatoid of the neurological deficit. arthritis
The Guillain-Barre syndrome has been associated with a variety of circulatory abnormalities3 and vasomotor disturbances have been accepted as a sudden cause of death.4 Thus autonomic function should be
15 SEPTEMBER 1979
SIR,-Dr P G J Forster and others (4 August, p 308) rightly warn against the use of Chueipills apparently Fong-Tou-Geu-Wan imported from Holland, for the treatment of
SIR,-It might be of interest to your readers that in addition to the Chinese herbal medicine Chuei-Fong-Tou-Geu-Wan, on which Dr P J G Forster and others report (4 August, p 308), four more exotic drugs-Amborum spesial F, Tsaitsaowan, Nose Pill, and Swasahar-claimed to be pure herbal remedies, were found by the German Mediciiles In-
spection Institute (Deutsches ArzneiprufungsInstitut, DAPI), an independent laboratory of the pharmaceutical profession, to contain dexamethasone or prednisolone or both. The
As far as the case report of Dr Lewis and others is concerned, it would be useful to know if the patient had acute or fulminant changes of exophthalmos, for without these changes their patient would be similar to one of our own who did not respond. The lack of response in such patients is probably due to permanent fibrotic changes in extraocular muscles. In this regard it would be extremely useful to have a simply measured biochemical marker which would predict potential responders. For the moment, however, it appears that one would have to depend on the clinical indications such as those described above; this is not necessarily a compromise since it is mostly in association with these features that the threat to visual acuity occurs. Plasmapheresis is not a treatment for cosmetic discomfort but a possible alternative to orbital decompression. We agree that this procedure needs further assessment. P DANDONA N MARSHALL S BIDEY A W NATHAN C W H HAVARD Metabolic Unit, Royal Free Hospital, London NW3 2QG
Autonomic neuropathy in the Guillain-Barre syndrome SIR,-Further to your correspondence regarding heart rate variation in diabetes mellitus and in tetraplegic patients (19 May, p 1353) we would like to report a case of GuillainBarre syndrome in which serial tests showed the presence and then resolution of an autonomic neuropathy.
BRITISH MEDICAL JOURNAL
monitored closely in this syndrome, both to rheumatoid disorders. However, they did not assess progress and to provide objective need to refer to a newspaper as a source of reference, since the matter has received wide parameters with which to assess therapy. publicity in the Dutch medical press. After the first warning that analysis of such M E EDMONDS R D STURROCK pills had shown the presence of indomethacin and dexamethasone, and that cases of Department of Therapeutics, Westminster Medical School, Cushing's and withdrawal syndrome London SW1O 9TH symptoms after stopping treatment had been Ewing, D J, et al, British Medical Journal, 1978, 1, 145. reported,' a case similar to Dr Forster's was 2 Sundkvist, G, et al, British Medical Journal, 1979, 1, published,2 involving a patient who had been 924. 3Birchfield, R I, and Shaw, C-M, Archives of Neuirology, using 12 pills daily containing an average of 1964, 10, 149. 75 mg indomethacin, 112 ug dexamethasone, 4 Appenzeller, 0, and Marshall, J, Archives of Neu4roand small quantities of diazepam and hydrology, 1963, 9, 368. chlorothiazide. These pills had been manufactured by the Nan Lien Pharmaceutical Co Ltd in Hong Kong. Similar pills from the Singapore subsidiary of the same firm were Diving and hypothermia shown to be composed of prednisone 0 4 mg, SIR,-Another two divers in the North Sea hydrochlorothiazide 4 mg, chlordiazepoxide have died from hypothermia and I should like 0 5 mg, chlorpheniramine maleate 1 3 mg, to add to the recent contributions on this and thiamine disulphide 5 mg; whereas the subject (5 May, p 1182; 9 June, p 1566; pills marketed by the Shou Sing Pharmaceutical Co Ltd in Taiwan contain varying 25 August, p 494). Divers under water lose heat from the body (0 6-6 mg) amounts of phenylbutazone, about surface and through respiration, the latter in 8 mg of aminopyrine, and some thiamine. two parts-(a) the humidification of dry Moreover, the Yi Chung Tai Medical Manuinspired gas and (b) absolute warming of the factory Co Ltd in Taiwan markets Chicold inspired gas. With a helium-oxygen Shi-Ton pills containing 8 1 mg paracetamol, respiratory mixture the absolute warming part 0-26 mg ethaverine hydrochloride, 2 mg of the respiratory heat loss becomes much chlorzoxazone, 0-55 mg diazepam, 1 9 mg more important than in air. Under normal caffein, and some thiamine.1 In none of these circumstances heat supplied from the support cases was the presence of these drugs ship to the diving bell via the umbilical cord mentioned on the package or the directions counteracts the heat loss; but in any accident folder. Obviously patients suffering from normal sources of power and heat will almost rheumatoid arthritis run great risks in the certainly be lost, as happened in the Thistle unauthorised use of such adulterated pills. Though marketing-mostly by small field, or at best reduced. When this happens the men are in trouble and emergency equip- Chinese dealers-of these pills in the ment should therefore be effective without Netherlands is alleged, and since October 1978 has been officially condemned, a total requiring any outside source of power. Respiratory heat loss could be reduced by embargo on this dangerous practice seems means of a heat exchanger which also acts as a almost impossible to enforce. Patients should condenser humidifier. A soda-lime-filled cani- therefore be clearly warned against the use of ster, as used in anaesthetics but with the any Chinese so-called herbal pills. This is not addition of insulation, could fulfil this need. the only example of its type; similar instances The soda-lime granules would initially act as a (Amborum Spezial F, Tsai-Tsao-Wan, passive-condenser humidifier and heat ex- "nose pills," and Swasahar) have been changer, but as the expired carbon dioxide reported from Germany, Australia, and the reacted with the soda lime to produce heat and United States.4 L OFFERHAUS moisture the system would gradually change M N G DUKES to one providing a positive heating effect. Of course, as the soda-lime became exhausted the Division of Pharmacotherapy, Drug Inspectorate, canister would revert to a passive heat and Cenltral Ministry of Public Health and Environmental Hygiene, moisture conserver. A single canister should nevertheless provide about six hours of Leidschendam, The Netherlanids H M SMITS positive heating and CO2 absorption. The provision of the insulated canisters State Institute for Drug Research, would encroach on the space in the diving bell Leiden, The Netherlands but a space of 30 x 15 cm diameter per man Offerhaus, L, Nederlandsch Tijdschrift voor Geneesmight not seem excessive for an emergency. kunde, 1978, 122, 1633. Uitdehaag, C M J, Nederlandsch 7'zjdschrift voor the fitting be (a) The other problems would Geneeskunde, 1979, 123, 1009. canister into the diver's breathing system; Central Drug Inspectorate, Nederlandsch lijidschrift voor Geneeskunde, 1979, 123, 1347. (b) a slight increase in resistance to breathing; Dukes, N M G, (editor), Side Effects of Druigs Annual and (c) a gradual increase in dead space as 3, Amsterdam, Excerpta Medica, 1979. the soda lime became exhausted.
A 30-year-old man presented to the casualty department with a seven-day history of numbness paraesthesiae of both legs and hands and a left facial weakness which had been present for two days. On examination, his temperature was 37-2°C; pulse rate 124 beats/min, regular; and blood pressure 120/80 mm Hg lying down, 110/80 mm Hg standing. There was a left lower motor neurone facial palsy, a proximal weakness of all four limbs, and sensory loss of a glove and stocking distribution with absent deep tendon reflexes. Investigations: haemoglobin concentration 15 9 g/dl, white blood cells (WBC) 10 5- l09/l; cerebrospinal fluid WBC< 1 x 106/1; protein 2-3 g/l. Electromyography showed slowing of sensory and motor conduction. A diagnosis of Guillain-Barr1 syndrome was made and corticotrophin therapy started. In view of the marked resting tachycardia serial tests for autonomic neuropathy were performed. The heart rate response to standing was conducted as described by Ewing et all and the "30:15 ratio" derived. The variation in heart rate during respiration was recorded by continuous electrocardiographic monitoring during deep breathing (six deep breathing manoeuvres in one minute) and the E:I ratio of the mean of the longest R-R interval during maximal expiration to the mean of the shortest during maximal inspiration was calculated as described by Sundkvist et al.2 For E LL LLOYD the first three days of his admission there was a persistent tachycardia and both the "30:15" and Department of Anaesthetics, Infirmary, the EB: ratios were compatible with vagal neuro- Royal Edinburgh EH3 9YW pathy and autonomic dysfunction. His neurological signs were unchanged. On the fourth day, however, these ratios returned to within the normal range. This was followed by a gradual resolution "Herbal" medicines and rheumatoid of the neurological deficit. arthritis
The Guillain-Barre syndrome has been associated with a variety of circulatory abnormalities3 and vasomotor disturbances have been accepted as a sudden cause of death.4 Thus autonomic function should be
15 SEPTEMBER 1979
SIR,-Dr P G J Forster and others (4 August, p 308) rightly warn against the use of Chueipills apparently Fong-Tou-Geu-Wan imported from Holland, for the treatment of
SIR,-It might be of interest to your readers that in addition to the Chinese herbal medicine Chuei-Fong-Tou-Geu-Wan, on which Dr P J G Forster and others report (4 August, p 308), four more exotic drugs-Amborum spesial F, Tsaitsaowan, Nose Pill, and Swasahar-claimed to be pure herbal remedies, were found by the German Mediciiles In-
spection Institute (Deutsches ArzneiprufungsInstitut, DAPI), an independent laboratory of the pharmaceutical profession, to contain dexamethasone or prednisolone or both. The
